Thank You Everyone!

Posted on July 15, 2014.

THANK YOU AGAIN! New Hampshire Union Leader’s  annual Readers’ Choice awards has listed New Hampshire ... Read More

On Call with the NH Medical Society

Posted on July 14, 2014.

On Call with the New Hampshire Medical Society will feature Dr. Vladimir Sinkov this Wednesday ... Read More

Best of NH Party 2014!

Posted on July 11, 2014.

Did you miss the Best of NH Party this year? Check out this video to ... Read More

New Hampshire Orthopaedic Center

MRI: Not the Whole Story – William P. Rix, MD

Posted on May 30, 2014.

MRI:  Not the Whole Story
William P. Rix, MD

MRI is an imaging tool commonly used by orthopedists in making a diagnosis in patients with musculoskeletal complaints.  It is frequently mentioned in the media when professional athletes are injured:

“Major League Baseball pitcher John Smith’s production has fallen over the past few games. MRI of his sore shoulder reveals no structural damage and rest is indicated.”

“National Football League lineman Jim White’s episodes of low back pain have limited his starts this season. An MRI showed he will need surgery and will be out for the rest of the season”.

The implication of these common references in the sports media is that an MRI offers the definitive answer for musculoskeletal problems.

MRI is a state-of-the-art imaging technique that depicts the anatomy of our musculoskeletal system in astonishing detail.  Despite its unquestionable value, however, it can be confusing and in some cases, downright misleading. This is because the abnormality seen on the scan may not be the cause of the patient’s problem. Remarkable as the technology is, it is no substitute for a good history and physical examination.

To illustrate, let’s look at some actual cases:

  • A 50-year-old man was referred to the orthopedist for possible surgery after an MRI revealed a small rotator cuff tear in his shoulder.  The patient told the orthopedist that he had experienced sudden onset of severe shoulder pain without injury in a previously normal shoulder.  His pain had subsided after 2 weeks, but left him with profound shoulder weakness. The physical examination revealed severe wasting of the supraspinatus and infraspinatus muscles, two important components of the rotator cuff. Because rotator cuff patients usually do not present with such extremes on history or examination, the orthopedist suspected something else was going on. Further muscle testing revealed subtle weakness of the Serratus Anterior, a muscle that holds the scapula (wing-bone) tight to the chest wall, a finding inconsistent with a primary diagnosisof rotator cuff tear. Electrical nerve studies confirmed that this man had inflammation of his brachial plexus, the network of nerves that runs from collarbone to armpit and   sends nerves to the shoulder girdle and arm.  Though the exact cause of this condition is unknown, the treatment is non-surgical. This man was instructed in an exercise program and his weakness resolved over the next 12 months. The cuff tear was not addressed because it was an incidental finding on MRI and did not contribute to the man`s symptoms.
  • A 75-year-old woman experienced severe knee pain when she twisted her leg getting up from the toilet. She arrived at her primary care physician’s office using a walker and unable to bear weight on that leg.  A knee x-ray showed no fracture, but an MRI of the knee revealed a torn meniscus (cartilage) and mild-to-moderate arthritis. She was referred to the orthopedist for possible arthroscopic surgery.  During thehistory, the orthopedist noted that the woman was very thin, her diet tended toward “tea and toast” rather than three nutritional meals per day and she smoked, all high risk factors for osteoporosis.  The physical examination revealed the knee was non-tender over the torn cartilage area and there was no effusion (water in the knee).  These negative findings were unusualfor symptoms coming from a torn meniscus as seen on her MRI.  Bending and straightening her knee while sitting (hip stationary) caused no pain, but doing the same maneuver in a supine position (hip free to move) reproduced her severe knee pain.  The orthopedist became concerned about a hip fracture because hip bone and hip joint conditions sometimes refer pain only to the knee rather than the more common areas of groin and buttocks.  An x-ray of her pelvis revealed a non-displaced fragility fracture of the hip, a break that occurs in osteoporotic bone after minor trauma. The danger was that the hip fracture might displace at any time causing pain, blood loss and even death. She underwent same day hip pinning surgery with complete resolution of her pain. She was also counseled on the proper treatment of her osteoporosis. The torn meniscus was not the root cause of this woman`s pain and therefore was ignored.
  • Our last example is a 65-year-old man with a six month history of increasing buttocks pain, right greater than left.  His pain was worse on walking and better with rest.  He had undergone low back (lumbar) surgery 10 years prior and experienced intermittent episodes of backache ever since.  An MRI of his lumbar spine showed lumbar stenosis (narrowing) at the site of the old surgery.  Spine physical therapy had been ineffective in reducing his pain significantly.  He was referred to the orthopedic spine surgeon for possible decompressive surgery at the area of stenosis. The history revealed that the man’s father was “loaded with arthritis” and his brother had undergone both total knee and total hip surgery for debilitating arthritis. The surgeon also noted that the patient, when getting onto the exam table, used his hand to assist in lifting his right leg from the vertical to the horizontal, a move more typical of hip problems than back problems. Physical examination of the hip revealed stiffness, and stressing the hips in rotation reproduced his buttock pain. Dedicated X-rays of his hips revealed bilateral osteoarthritis, right greater than left.  Since both lumbar stenosis and hip arthritis can cause buttocks symptoms, further testing were needed to identify which condition was the primary pain generator. An injection into both hip joints with steroid and Xylocaine completely relieved this man’s pain, thus confirming that his buttocks pain was coming from his hips and not from his low back. This man eventually underwent total hip replacement on both sides, as the steroid`s benefit was only temporary. The coexisting lumbar stenosis was not the root cause of this patient’s problem and was left alone.

In all three cases, the MRI showed a true structural abnormality that could be corrected surgically.  However, one does not operate on an abnormality just because it`s there.  It has to be the cause of the patient`s problem.  The MRI did not tell the physician if the findings seen on film were actually causing the patient’s symptoms. An MRI cannot stand by itself. It must be ordered and interpreted in the context of a proper history and exam. In these patients, the MRI findings were age-related or post-surgical and not contributing to their complaints.

The proper sequence in arriving at the root of a patient’s orthopedic problem is a thorough history, a proper examination and, usually, an x-ray.  If further investigation is needed to come to a specific diagnosis, further testing, including MRI is then employed.

Since the time of Hippocrates, the backbone of delivering good patient care has been the history and physical. It still is.

Every Day Kids Suffer Concussions – What You Need to Know

Posted on May 13, 2014.

What is it?

A concussion is an injury to the brain that alters its function, the effects of which are usually temporary. These effects are variable and can include difficulty with concentration, memory, balance, and coordination.

Symptoms

These can range from very subtle, to obvious and severe. Headache, loss of memory, and confusion are often seen. Loss of memory can include events prior to the injury and will often include loss of memory of how the injury occurred.

MOST CONCUSSIONS DO NOT RESULT IN LOSS OF CONSCIOUSNESS.

Things to look for include:

  • Headache/pressure
  • Dizziness
  • Confusion/fogginess/amnesia to event
  • Dazed appearance
  • Delayed response to questions
  • Ear ringing/slurred speech
  • Loss of consciousness
  • Nausea/vomiting

Seizures, altered vision, pupils that don’t appear symmetric, or prolonged loss of consciousness require immediate evaluation

Causes

The brain is a very delicate structure encased in a solid container (skull). Anything that causes the brain to knock up against the side of the skull may result in a concussion. A DIRECT BLOW TO THE HEAD IS NOT REQUIRED TO RESULT IN A CONCUSSION, NOR IS DIRECT CONTACT. Rapid deceleration of the head can cause the brain to hit the skull and result in a concussion.

Risk Factors

Participation in collision sports such as lacrosse (in this case) is a risk factor. Another very important risk factor is having had a previous concussion.

Testing/Evaluation

On field evaluation includes evaluating consciousness and protecting any neck injury. There are various sideline tools used to assess the athletes symptoms and ability to recall or think. These are brief screening tools for the in-game setting which are usually followed by more comprehensive neurocognitive testing.

There is no routine x-ray or medical test to diagnose concussion. CT SCANS AND MRIs ARE TYPICALLY NORMAL with a concussion. If a patient develops specific neurological symptoms such as prolonged or worsening pain, loss of vision, asymmetric pupils, repeated vomiting or seizures CT scans and/or MRI can tell if there is bleeding on the brain that may be the cause.

Treatment

1. “When in doubt, keep ‘em out”. The first step is removing the athlete from participation as soon as a concussion is suspected.

2. Rest. This includes rest from both physical and mental activity. This includes all “thinking” activities like reading, video games, TV, etc.

3. Tylenol (acetaminophen) is useful for headaches, but NSAIDs such as Ibuprofen (Motrin, Advil), Aleve, and Aspirin are NOT recommended, as this may increase the risk of bleeding.

4. Progression back to activity begins with mental activity first.

5. Some studies have suggested that gentle exercise that keeps the athlete below their symptom threshold might help decrease the possibility of post concussion syndrome and help both athletes and non-athletes return to activity.

Return to Play

Most athletes will have resolution of symptoms after two weeks and a return of their neurological testing to a baseline (“normal”) in 7-10 days. Internationally accepted return to play criteria includes:

  1. The athlete must have no symptoms at rest
  2. The athlete must have no symptoms with full mental and physical exertion
  3. Balance testing must return to baseline
  4. Neurocognitive (brain/thinking) testing must return to baseline.

Once an athlete has no symptoms at rest, they can then progress through a guided protocol of rehab to return to play. Each stage takes 24 hrs, so that it takes at least 5 days to progress through the protocol prior to full game participation.

Prevention

Education!!

Preventative measures are of paramount importance in high risk sports. Players, Coaches, and parents have a role to play in not only recognition of sports concussions, but in changing the behavior and culture that may result in concussion. Many players, coaches, and parents may feel like aggressive behavior is required in certain sports. These feelings are often heard expounded from the sidelines. Proper technique, age appropriate rules for contact, and sportsmanship can result in decreased incidence of concussions.

Helmets and new helmet technology have been shown to decrease the risk of concussion and newer technologies are promising.

There is lack of conclusive evidence that the use of a mouth guard or specific types of mouth guards reduce the risk of concussion. Mouth guards do, however, reduce the risk of dental trauma which makes them invaluable in that role.

Complications

Post Concussion Syndrome is the persistence of any of the following after a concussion: headaches, dizziness, fatigue, irritability, difficulty with concentration and mental tasks, memory impairment, insomnia, and reduced tolerance to stress.   It’s suspected if these symptoms persist more than 1-6 weeks after initial injury.    Athletes who present initially with more symptoms take longer to recover.

Epilepsy: The risk of developing Epilepsy is doubled in the first 5 years post concussion.

Second Impact Syndrome: This is when an athlete sustains 2 successive injuries before recovery of the first is complete. Younger athletes seem especially susceptible to this, which can be a devastating complication leading to rapid brain swelling and death. Second Impact Synrome highlights the importance of restricting athletes from play until they have NO SYMPTOMS.

CTE (Chronic Traumatic Encephalopathy): This is a degenerative condition of the brain that occurs years after recovery. It is the topic of much conversation and research. Early in CTE, patients can have problems with irritability, depression, and poor memory. Later on, it can affect physical movement and speech. (See Junior Seau, Jim McMahon, both former NFL players)

Resources

There are multiple resources available for education for players, parents, coaches, and trainers on this topic which include programs for preseason baseline testing for players which is instituted in many local high schools and routinely at the collegiate and professional levels.

 NCAA Concussion in Sports www.ncaa.org/wps/portal/ncaahome?WCM_GLOBAL_CONTEXT = /ncaa/NCAA/Academics+and+Athletes/Personal+Welfare/Health+and+Safety/Concussion
 Centers for Disease Control and Prevention Heads Up Toolkit for High School Sports www.cdc.gov/concussion/HeadsUp/high_school.html
 Centers for Disease Control and Prevention Heads Up Toolkit for Schools www.cdc.gov/concussion/HeadsUp/schools.html
 Centers for Disease Control and Prevention Heads Up Toolkit for Physicians www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html
Computerized neuropsychological tests
 ImPACT www.impacttest.com
 CogState www.cogstate.com/go/sport
 HeadMinder www.headminder.com
 U.S. Army Medical Department, Automated Neurocognitive Assessment Metrics (ANAM) www.armymedicine.army.mil/prr/anam.html

**The Journal of Bone and Joint Surgery Current Concepts Review, Vol 94, Issue 17

Another I would add to this is sportslegacy.org, which is an organization headed by Chris Nowinski and Dr. Robert Cantu with cutting edge education and policy on this enormously important matter. There are several links and guides to setting up and maintaining an active concussion surveillance and management program for teams and institutions.

Osgood Schlatter’s Disease

Posted on April 13, 2014.

What Is It?

An overuse syndrome resulting in painful inflammation at the top of the shin bone where the patellar tendon attaches to the bone in an adolescent or preadolescent athlete.

Symptoms

This condition is marked by pain and tenderness with or without (usually with) a bump at the top of the shinbone (tibia). The pain is often increased with activity (or just after finishing the activity), and is often relieved with rest. It may be associated with a noticeable tightness in the muscles in the front and in the back of the thigh.

Causes

An apophysis is a growth plate that does not contribute to the length of a bone. Growth plates are made of cartilage. Cartilage is weaker than bone in the immature skeleton. Apophyses are often found at sites where tendons attach to bone. Apophysitis is inflammation at these attachment sites, the adult equivalent of which is tendonitis.

Repetitive activities, such as jumping, running, pivoting, etc. , coupled with a child who is growing, can lead to increase pull and tension on these delicate areas. This leads to pain and inflammation in those areas. The body may attempt to repair these areas by forming more bone, leading to a lump forming.

Risk Factors

  • Age: Usually 11-14 or so, boys 13-14, girls 11-12.
  • Gender: Boys more often than girls, but that gap is closing quickly.
  • Sports participation: Up to 20% of child athletes are affected. There is only a 5% incidence in nonathletes.

Testing

Osgood-Schlatters is a clinical diagnosis. A plain X-ray is often obtained to rule out other less common problems and to sometimes confirm the diagnosis. MRI IS NOT NECESSARY TO DIAGNOSE THIS CONDITION.

Treatment

  • REST, REST, REST. This can be the most difficult treatment given children’s early sports specialization and year-round participation in a single sport.
  • Icing and Stretching – Frequent icing is very useful and stretching the quadriceps is important.
  • Pain Control – Medications such as Tylenol or non-steroidal anti-inflammatories, such as Ibuprofen may be used to control pain.
  • Physical Therapy – Physical Therapy is often useful to help decrease pain and educate patients and families about stretching and safe strengthening techniques. Often rapid growth leads to increasing lengths of bones and tightness is muscles as they attempt to keep up with the growth.
  • Cross Training – Participating in other activities, such as biking and swimming provides fitness and activity without the undesired effect of the pounding.
  • Home Remedies – a strap that can be placed just above the tender area can be purchased at sports stores and may help take tension off of the affected area.

 

Do I Need An MRI?

Posted on April 4, 2014.

When I see patients in the office with knee or hip pain, I am often asked, “Do I need an MRI?”  and “I had an MRI, why do I need X-rays?”

There are many different imaging studies that physicians use to evaluate painful or injured joints.   An X-ray is typically the first study that is obtained.  Why do we get X-rays if other tests, like an MRI, show more detail?  Different images give different information.   X-rays are best for looking bones.  Fractures can be seen in more detail on an Xray than on an MRI, for example.  Moderate and severe arthritis can also be better visualized on X-rays.    A CT scan is a special type of X-ray which gives three dimensional cross sectional images.  It is excellent at evaluating bony anatomy.   However, it does expose patients to quite a bit of radiation.

In contrast, an MRI images soft tissues (such as ligaments and meniscus) more clearly than X-rays.   No radiation is used to create the images obtained by an MRI.   A very strong magnetic field is used to obtain the images.  An MRI takes about an hour to perform and requires the patient to lay very quietly in a narrow tube.  Unlike an X-ray, only one body part can be imaged at a time.  It takes twice as long to do an MRI of two knees compared to only one.  Some people are unable to have an MRI because of metal implants (stents in heart or brain), pacemakers or claustrophobia.

When do you need an MRI?  An MRI should be used to look for a specific abnormality suspected based on history or physical exam.  Examples include rotator cuff tears, meniscal tears, labral tears, avascular necrosis, or ligament tears.

Many patients with arthritis wonder, ‘Why I do not need an MRI to diagnosis arthritis or to plan a knee or hip replacement?’   X-rays are better at evaluating end stage arthritis than MRIs.  If you have arthritis on an x-ray, an MRI will likely not change the treatment recommendations and therefore is not needed.  It is also important to know that just because a test is abnormal does not mean that the pain is caused by the abnormality.   For example, if an MRI of the knee shows a torn meniscus on the outside of the knee but the patient’s pain is on the inside part of the knee, that torn meniscus is not causing the pain.

There are many imaging tests available to help physicians diagnose the cause of joint pain.   Usually there is not one definitive test that gives an answer, but a combination of physical exam and diagnostic studies which leads to a diagnosis.  While MRI can be helpful, it is not always needed.

Life After Joint Replacement

Posted on April 3, 2014.

The sky was deep blue without a single cloud as I stood by the field at the Pepperell airfield, watching a patient fulfill his dream of skydiving with his granddaughter.  Six months earlier, when we discussed replacing his hip, I told him that the two things that I absolutely do not recommend doing after joint replacement are jumping out of airplanes and running marathons.   Crestfallen, he explained to me that skydiving was on his “bucket list” of things to do, and it was one of the many things he was unable to do because of his hip arthritis.   “Maybe just one time” I told him, not really expecting that he would go through with his plans.   And now, here we were.  He had recovered quickly after his surgery, and now was ready to fly with his new hip.  I scanned the sky, watching his chute deploy and glide gracefully towards the earth.  I held my breath and was relieved to see his smile and thumbs up after he landed safely.

What can you do after a joint replacement? Just about anything you want to do.  The goal of joint replacement surgery is to get you back doing the activities you enjoy.  Recently I watched another patient complete in a regional tennis tournament after her knee replacement.   Many of my joint replacement patients enjoy gardening, walking, hiking, biking, snowshoeing, and skiing.  However, there are some activities that are discouraged.  For example, high impact activities such as distance running or singles tennis should be avoided because of the risk of the joint wearing out prematurely.  Similarly, high risk activities such as skydiving or black diamond skiing are not recommended due to the risk of a fracture or dislocation.

After recovering from their hip or knee replacement, patients often say to me “You gave me back my life.”  The most rewarding part of being a joint replacement surgeon is hearing about (and sometimes witnessing) the fun things that people can do without pain after their joint replacement surgery.  Although surgery is not without risk, for patients who have severe arthritis that is limiting their activities, joint replacement surgery can be a life altering experience.